Description

Systemic disorder caused by acute and/or chronic intoxication from salicylate-containing medications:

• Following accidental or intentional exposure, toxic actions of salicylates include:
  • Stimulation of CNS respiratory center
  • Uncoupling of oxidative phosphorylation
  • Inhibition of Krebs cycle dehydrogenases
  • Stimulation of gluconeogenesis
  • Increased lipolysis and lipid metabolism
  • Inhibition of aminotransferases
  • Cyclo-oxygenase inhibition and decreased production of clotting factors
  • Irritation of the gastric mucosa and stimulation of the CNS chemoreceptor trigger zone
• These actions cause sequential and progressively severe physiologic abnormalities with increasing doses of salicylates, time following exposure, duration of chronic exposure, extremes of age, and presence of concurrent medical conditions; abnormalities include:
  • Respiratory alkalosis accompanied by progressive metabolic acidosis
  • Hyperpyrexia
  • GI, renal, pulmonary, and skin losses of body fluids and electrolytes
  • Initial hyperglycemia followed by hypoglycemia, particularly CNS hypoglycemia
  • Abnormal hemostasis and coagulation
• Clinical presentation of patients with salicylate toxicity can range from minor symptoms to a syndrome initially indistinguishable from septic shock with multiple organ failure, including encephalopathy and acute respiratory distress syndrome (ARDS).
• The very young and elderly are particularly prone to develop severe toxicity, as are those with chronic intoxication.
• Conditions causing concurrent acidosis may increase tissue concentrations of salicylate and result in greater morbidity and mortality.
• System(s) affected: Cardiovascular; Endocrine/Metabolic; Gastrointestinal; Hematologic/Lymphatic/Immunologic; Musculoskeletal; Nervous; Pulmonary; Renal/Urologic; Skin/Exocrine

• Increased risk for chronic toxicity because of decreased renal function
• Increased risk for bleeding or perforated gastric ulcers in patients >70 years of age

Pediatric Considerations
Acidosis is often more severe in the very young, particularly in chronic or repeated therapeutic-dose poisonings.

• Salicylates may cause premature closure of ductus arteriosus in the fetus.
• Increased risk of ante- and intrapartum hemorrhage

Epidemiology

Incidence/Prevalence in the US:

• >10,800 single-substance ingestions of acetylsalicylic acid (ASA) or ASA combination products reported by poison control centers in 2010.
• 24 deaths in 2010, none in children <6 years of age
• Occurs in children and adults at any age

Risk Factors

• Dehydration
• Conditions causing metabolic or respiratory acidosis
• Extremes of age—very young and elderly
• Psychiatric illness
• History of previous toxic ingestions or suicide attempts
• Concurrent oral poisoning with other substances
• Concurrent use of acetazolamide (Diamox)

General Prevention

• Patient and parent/caregiver education essential; see “Patient Education”
• Emergency telephone numbers (poison control centers): (800) 222–1222

Etiology

• Accidental or intentional ingestion of salicylates or salicylate-containing medications
• Percutaneous absorption of dermatologic medications containing salicylate
• Breastfeeding by mothers ingesting salicylate-containing medications
• Teething gels containing salicylates

Commonly Associated Conditions

Reye syndrome with salicylate use and varicella or influenza viral infection